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SAN 10AQUIN Environmental Health Department <br /> COU rel T Y-_.__- <br /> e Grvainesi (mows heft. <br /> New Well Information <br /> Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption <br /> criteria must submit the following required information, to the extent that can be reasonably known. <br /> The Environmental Health Department must collect this information before a new well permit is <br /> issued and must post the information on the Department's website for public information. <br /> WELL LOCATION AND OWNER INFORMATION <br /> Well Location Address: 4 S. W a R- M I City: Iq poN 531D V <br /> Well Location APN: 2-145_ _ <br /> 0-70 11 <br /> Well Latitude: '( Well Longitude: --'Z - <br /> Flood Plain Designation: Well Elevation: + <br /> Applicant Name: N1Mjtyj JWApplicant Title: <br /> Applicant Address: wtqA sN Q N Z city: fl POM <br /> Applicant Phone: 20, - 444 . Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: city: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft): Acres to be Served by Well: <br /> Use of Well: Domestic Irrigation ❑Small Public Water Supply EI Municipal Public Water Supply ❑Industrial ❑Stock <br /> D Other: lt7Q ski _ <br /> Depth of Corcoran Clay(ft): N <br /> Proposed Well Capacity(gal/ft): Estimated Pumping Rate(gallmin): <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): ?i <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXISTING WELLS INFORMATION <br /> Total Number of Existing Wells on Property: <br /> Please complete the information below for every well on property.Use extra paper if needed <br /> Well#1 Information <br /> Use of Well: omestic ❑ Irrigation ❑Small Public Water Supply ❑Municipal Public Water Supply ❑Industrial ❑Stock <br /> ❑Other: <br /> Total Depth(ft): ,1,00 To: From: <br /> Casing Diameter(in): x' ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet: Estimated ❑ Measured <br /> Specific Capacity(gaVminlft):i <br /> Other Pumping Tests Performed:: Test Result: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjcehd.com <br />